key: cord-0794620-lqg8o2ig authors: azevedo, v. F.; Peruffo, l. c. B.; Nogueira, G. m.; hajar, f. N.; Novakoski, g. k. O.; rafael, l. k.; Brugnari, r. g. d. O.; Vanzela, L. E.; Larocca, S. d. B. title: STRATEGY FOR THE CONTAINMENT, MITIGATION, AND SUPPRESSION OF THE COVID-19 PANDEMIC IN FRAGILIZED COMMUNITIES ON THE PERIPHERY OF A LARGE BRAZILIAN CITY. date: 2020-09-29 journal: nan DOI: 10.1101/2020.09.28.20203174 sha: 77c814d05b8bf9971b2f4a42b778aae1328526cc doc_id: 794620 cord_uid: lqg8o2ig INTRODUCTION.Prevention measures are highly important to poor communities because surveillance and access to health care may be limited.OBJECTIVES We aimed establish measures to contain and suppress the spread of COVID-19, associating education, active case tracking, and humanitarian aid in two needy communities in Brazil. The adherence to the measures and evolution of the number of cases were verified during the project.MATERIALS AND METHODS.The target population consisted of approximately 1300 participants(350 families). A collection of epidemiological data was performed in family members registered for the project. Rapid tests were performed on people who had symptoms and their contacts. Scientific information through audio-visual materials,educational pamphlets written in colloquial language, food parcels,masks,hygiene and cleaning materials were provided directly to family nuclei. RESULTS The common needs faced by families were food inputs and/or ready-to-eat food, mentioned by 91.4% (233) of the people, and hygienic and cleaning materials, mentioned by 30.6% (78) of the people. Only 34.9% (84) of families had 70% rubbing alcohol or hand sanitizer gel at home.The most frequently cited sources of information on COVID-19 were television [cited by 82.4% (210) of the people]; social media [25.5% (65)]; friends, neighbours, or family members [13.7% (35)]; and radio [11.4% (29)] .A total of 83.7% (175) stated that the actions helped them to avoid leaving the community.CONCLUSIONS Community isolation may be the best way to contain the spread of pandemics in fragile populations with low socio-economic status.Educational actions combined with rapid testing and humanitarian aid were objective forms to promote community isolation. The COVID-19 pandemic is an ongoing pandemic of an acute respiratory disease caused by the new severe acute respiratory syndrome coronavirus (SARS-CoV-2). [1] The disease was first identified in Wuhan, Hubei Province, People's Republic of China, on 1 December, 2019, and the first case was reported on 31 December of the same year. [2, 3] It is believed that the virus has a zoonotic origin because the first confirmed cases were mainly linked to the Huanan Wholesale Market, which also sold live animals. [4] [5] [6] On 11 March 2020, the World Health Organization declared the outbreak a pandemic. [7.8] In Brazil, the emergency alert was raised to level 2 (out of 3) on 28 January 2020, meaning it was considered an 'imminent danger' to the country. [9] The notification of cases of COVID-19 is managed by the Integrated Health Surveillance Platform of Ministry of Health. We currently have had 3,501,975 cases and 112,304 deaths in Brazil. [10] Prevention measures are highly important to poor communities because surveillance and access to health care may be limited. [11] However, preventive measures such as frequent hand hygiene and social distancing are suboptimal in these populations. The lack of water and cleaning products hinders frequent hand washing and sanitizing of objects. [12] [13] [14] A modelling study concluded that social distancing in a respiratory virus pandemic is 60 to 70% less effective in reducing the attack rate in an underdeveloped population than in a developed population. [15] This lower effectiveness is attributed to greater numbers of people in the same household, which imply a higher proportion of intradomicile transmissions of the virus -which are not prevented by social distancing -out of the total transmissions. [15] In addition, low-income individuals may be more averse to social distancing due to the need to work to provide food for their families, their lower flexibility in finding/changing jobs, their fear of losing their jobs, and their lack of formal jobs with working conditions set by law. [12] [16, 17] The lack of knowledge about the disease may also cause lower adherence to prevention measures. Knowledge about the disease is positively correlated with education and the adoption of prevention practices for both COVID-19 [18] and other diseases caused by respiratory viruses. [19.20] There are several strategies to control an outbreak: containment, mitigation, and suppression. The containment measures are performed in the early stages of the outbreak and aim to locate and quarantine cases of infection, in addition to vaccination and other measures to control the infection to stop it spreading to the rest of the population. When it is no longer possible to contain the spread of the disease, the measures focus on delaying and mitigating its effects on society and the health system. Containment and mitigation measures can be performed simultaneously. [21] Suppression measures require that more extreme measures be taken to reverse the pandemic by decreasing the reproductive number to less than 1. [22] Part of the management of an outbreak of an infectious disease consists of trying to reduce the epidemiological peak, a process called 'flattening the epidemiological curve'. [23] This reduces the risk of overburdening health services and gives more time for new vaccines and treatments to be developed. Among the non-pharmacological interventions that control the outbreak are personal prevention measures, such as washing hands, wearing face masks, and voluntary quarantine; community prevention measures, such as closing schools and cancelling events that gather large numbers of people; environmental measures, such as cleaning and disinfecting surfaces; and measures that promote social adherence to these interventions. [24] Among the suppression measures taken in some countries are quarantines of several cities, travel bans, [25] mass screening, financial support for infected individuals so they isolate themselves, fines for those who break isolation, criminalization of stocking up on medical materials, [26] and compulsory reporting of flu-like symptoms. This study aimed establish measures to contain and suppress the spread of COVID-19, associated with education, active case tracking, and humanitarian aid in two needy communities in the metropolitan region of Curitiba, Brazil, involving medical students from the Federal University of Paraná (UFPR) and volunteers. It also aimed to verify the effects of these measures on the outcome of adherence to the measures and evolution of the number of cases detected during the project. The general idea was to conduct a programme that could be globally reproduced and applied in any pandemic outbreak in fragile communities based on two basic and non-exclusive principles: education and humanitarian aid. The target population of the present interventional study consisted of needy populations from the periphery of the municipalities of Curitiba (Caximba neighbourhood) and Araucária (Jardim Israelense neighbourhood), totalling 350 families (approximately 1,300 participants). The Caximba community is located south of Curitiba. It has a population of predominantly European origin and an area of 8.22 km 2 . [27] In 1989, a sanitary landfill was created in this region, which received waste from Curitiba and the metropolitan region. [28] After the landfill stopped being used in mid-2009, 'Vila 29 de Outubro' was formed, the largest village in the region of the Caximba neighbourhood. Considered an irregular settlement area, since the land belongs to the Institute of Waters of Paraná, the community was built on flooded land, without basic sanitation. [29] At least 1.1 thousand families inhabit these places unfit for dwelling. [30] The Caximba neighbourhood has 767 households, with an average of 3.29 inhabitants per household. This makes this community more crowded than Curitiba, which has an average of 2.76 inhabitants per household. [27] Thus, the site highlights the risk of spreading infectious diseases. In addition, only 4.44% of the households of this neighbourhood are connected to the general sewage network, raising the propensity to spread diseases that involve intestinal transmission. [27] In the Capela Velha neighbourhood of Araucária, there are two large communities that were formed by land invasion: the Jardim Israelense community and 21 de Outubro community. Capela Velha is to the northwest Araucária and has approximately 25,000 inhabitants, 3.1% of whom are over 65 years old. [31] The 21 de Outubro community was established in a portion of the Jardim Israelense affected by flooding near the Passaúna River dam. More than 300 families lived in this flooded portion until the Jardim Arvoredo II subdivision was completed, enabling approximately 170 families to be relocated. [32] Data from the Department of Planning of the Araucária city hall show the poverty of the region: 60% of the residents have an income between one and two minimum wages and 13% of the residents an income below that amount. [33] The patient care, educational procedures, and collection were done by students enrolled in health and medical courses of the medical schools of Curitiba and other volunteers. The following procedures were performed: 1) Collection of epidemiological data from the studied populations as well as data on their knowledge of COVID-19 2) Performance of rapid tests on people from the community who had symptoms (suspicions) and their contacts. The tests were immunochromatography (intravenous blood collection and local verification of IgG/IgM positivity), which is indicated for patients with more than 10 days of symptoms suggestive of COVID-19, and RT-PCR, which is indicated for people with suspected active COVID-19 for less than 7 days. 3) Provision of scientific information and answering the population's questions through audio-visual materials and educational pamphlets written in colloquial language, produced by the group of volunteers and distributed in the course of their activities. 4) Provision of food parcels, masks, hygiene, and cleaning materials directly to family nuclei to reduce the need for residents to go outside the community in search of humanitarian aid. A questionnaire was applied in the form of a direct interview in the case of people with restricted or non-existent access to the Internet. For others, the questionnaire was published on the Google Forms platform, and its content was divided into three blocks: . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. A total of 255 people were included in the study. Each one represented a family registered for the project. A total of 79.6% (203) were women and 20.4% (52) were men, with a mean age of 39.9 (± 13.1) years [ Table 1 ]. The mean number of people per family was 3.8 (± 1.6), the mean number of children or adolescents up to 16 years old was 1.6 (± 1.3) per family, and the mean number of elderly people per family was 0.2 (± 0.4). A total of 74.1% (189) of families . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 29, 2020. . https://doi.org/10.1101/2020.09.28.20203174 doi: medRxiv preprint had at least one person up to 16 years of age, and 14.1% (36) of families had at least one elderly person. A total of 8.6% (22) of the people were illiterate, 11.4% (29) had studied up to literacy, 48.2% (123) had studied through elementary school, 12.5% (32) had an incomplete secondary education, 15.7% (40) had a complete secondary education, 1.6% (4) had an incomplete higher education, and 0.4% (1) had a complete higher education. The monthly family income varied between zero and two minimum wages. A total of 7.4% (19) of the people reported not having a family income at the time, 54.5% (139) had a family income less than or equal to half the minimum wage, 29% (74) had a family income greater than half the minimum wage but less than or equal to one minimum wage, and 6.3% (16) had a family income greater than one but less than or equal to two minimum wages. The Among the people who reported leaving the community, 43.9% (29) mentioned essential purchases -food and alcohol, for example -and 18.2% (12) mentioned work as a reason. A total of 33.3% (22) of the people who regularly left the community took public transportation. A total of 81.8% (206) answered that they could stay at home for 14 days in case of suspected or confirmed COVID-19. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 29, 2020. . https://doi.org/10.1101/2020.09.28.20203174 doi: medRxiv preprint Only three people (1.4%) responded that our actions did not help them avoid leaving the community. A total of 83.7% (175) stated that the actions helped them a lot, and 14.8% (31) stated that the actions helped them a little to avoid leaving the community. The mean number of COVID-19 symptoms correctly cited by the interviewees increased from 2.16 on the first test to 2.37 on the second test [ Table 4 ]. The most cited were fever (from 66.3% to 72.5%), body pain (from 51.4% to 48.2%), dyspnoea (from 56.5% to 47.5%), and cough (from 40.4% to 43.5%). On the first test, 27.5% of people cited symptoms that are not commonly found in COVID-19, and 4.3% of people said they did not know any symptoms. In the second test, these percentages were 10.6% and 5.1%, respectively. A total of 47.5% of people at the time of the first test and 62.7% at the time of the second test knew that they would need to be quarantined for 14 days if they presented symptoms of COVID-19. The proportion of respondents who knew they did not need medical care . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 29, 2020. . Like transmission, mortality is higher in poor populations in a respiratory virus pandemic. In the 1918 and 1919 pandemics, mortality was seven times higher in poor regions, such as sub-Saharan Africa, Southeast Asia, and Latin America, than in developed regions, such as Europe and the United States. [34, 35] One study concluded that in a hypothetical pandemic similar to that of 1918, 96% of deaths would occur in developing countries. [35] In addition, the mortality of an influenza pandemic is negatively correlated with per capita income, which alone explains approximately 50% of the variation in mortality. [35] A 10% increase in per capita income implies a 9 to 10% reduction in mortality. [35] This higher mortality of a respiratory virus pandemic in needy populations may be due, at least in part, to the prevalence of comorbidities such as tuberculosis, AIDS, and chronic malnutrition. [16] [36] Factors discussed above, such as higher population density and poor housing conditions, may also contribute to increased mortality. [37] Needy communities are especially vulnerable to pandemics. Although there are still no studies on the transmission of coronavirus in these communities, a study on a hypothetical pandemic of a new influenza strain estimated that the attack rate in underdeveloped populations may be 50% higher than the attack rate in developed populations, mainly due to the larger number of people living in the same household. [15] Under conditions of overcrowded housing, small houses with poor ventilation, and housing with a single room, social distancing is impractical, as is the isolation of people who show symptoms, which predisposes the residents of the community to higher transmission of respiratory viruses. [13] [38,39] Other factors that may contribute to the transmission of respiratory viruses among residents of poor communities are the sharing of utensils and the use of public transportation. [16] [39] In addition to the disease itself, poor communities face difficulties indirectly caused by the pandemic, such as reduction or annulment of their income and loss of support for possible social actions that help the community. [14] Thus, given the greater risks of COVID-19 transmission and mortality in needy communities, as well as the difficulties of implementing preventive measures and the aggravation of basic needs by the pandemic, the importance of actions specifically designed to help this population becomes . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 29, 2020. . clear, as the measures proposed for other populations are not efficient in these communities. Although most of the people interviewed had no income or had an income less than one minimum wage, most had access to TV and social media, such as Facebook and Instagram, and obtained most of their information about COVID-19 from TV shows or national television news or from social media ( Table 2 ). The application created by the Ministry of Health was rarely cited, and only one person accessed pandemic information through this public website. This demonstrates that public initiatives in Brazil need to be better publicized by the government to the poorest sections of the population. As documented in the initial interviews and in the reapplication of the survey, most residents were already afraid to leave the community, and in general, they only did so for work reasons or to make purchases essential to their family's subsistence. This facilitated our educational goal of emphasizing the need for residents to remain in the community during the pandemic. While implementing this project and according to the data obtained from the registration of more than 300 families, we noticed that there was a potential circulation of the virus from the third week. Thus, we decided to apply a second questionnaire to assess the residents' knowledge about COVID-19, as well as the reasons that led them to circumvent social distancing and expose themselves to the virus. In the fourth week, in addition to lunch boxes and food parcels, masks and bread were also distributed, which were obtained through partnerships with institutions that support movements and projects in fragile populations in Brazil. The second questionnaire was administered to residents already registered with the project. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 29, 2020. . https://doi.org/10.1101/2020.09.28.20203174 doi: medRxiv preprint A potential shortcoming of our study was that we did not compare the impact of our actions on the spread of COVID-19 in other needy populations that did not have access to the same measures, near the locations where we operate. However, this was not our goal. Our goal was simply to know how much the population had improved in terms of their knowledge about the pandemic and how our activities improved their adherence to the containment measures. Community isolation may be the best way to contain the spread of pandemics in fragile populations with low socio-economic status. Educational actions combined with rapid testing and humanitarian aid are objective forms of aid that are well evaluated by these populations as promoting community isolation. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 29, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 29, 2020. . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 29, 2020. . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 29, 2020. . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 29, 2020. . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 29, 2020. . https://doi.org/10.1101/2020.09.28.20203174 doi: medRxiv preprint Pandemic influenza preparedness and response among public-housing residents, single-parent families, and low-income populations Impacts of COVID19 on vulnerable children in temporary accommodation in the UK. The Lancet Public Health Redefining vulnerability in the era of COVID-19. The Lancet Pandemic influenza in Papua New Guinea: A modelling study comparison with pandemic spread in a developed country Pandemic influenza planning in the United States from a health disparities perspective. Emerg Infect Dis Effective health risk communication about pandemic influenza for vulnerable populations